Provider Demographics
NPI:1275649279
Name:EPPS VILLAGE FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:EPPS VILLAGE FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:HERSCHEL
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:706-227-0773
Mailing Address - Street 1:1720 EPPS BRIDGE PKWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-6132
Mailing Address - Country:US
Mailing Address - Phone:706-227-0773
Mailing Address - Fax:706-227-1642
Practice Address - Street 1:1720 EPPS BRIDGE PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-6132
Practice Address - Country:US
Practice Address - Phone:706-227-0773
Practice Address - Fax:706-227-1642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN008795261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADN008795OtherSTATE DENTAL LICENSE #